Playsmart Site Survey and Agreement

Play Smart Youth Heart Screening Request Form
Welcome to Play Smart
Thank you for your interest in hosting a Play Smart screening event. Please fill out the following application to host an event.

Play Smart is powered by Basecamp Prevention + Wellness, part of the Providence Heart Institute.

Organization Background Information
Organization Name
Are you within our geographic boundary?
Is your organization a non-profit?
What is your EIN?
Contact Name

First NameLast Name
Title
Title held within the organization. Examples: Executive Director, Board member, Staff Member, ect
Contact Phone Number of Person Completing the Form
Please enter a valid phone number.Format: (000) 000-0000.
Email Address of Person Completing the Form
example@example.com
Please provide a brief desctiption of your organization.
What is your organization's address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this where the screening will be held?
Please enter where the screening will be held.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is there anything else we should know about the screening site?
Backup contact, optional

First NameLast Name
Backup contact email, optional
example@example.com
How did you hear about us?

Screening Preferences
Preferred month of screening
Must be at least 12 weeks from time form is filled out; we will do our best to accommodate
Preferred time of day for screening.
Preferred day for screening.
How many community members are you anticipating will receive a screening?
Note participants must be between ages 12-18 at the time of the screening
Would you be open to people from the surrounding area or another organization being screened too?

Play Smart Youth Heart Screening Request Form